Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Sunday, January 19, 2014

The Importance of Demonizing Specialists

Most of us would agree that health care costs are too high
in America. They must be controlled or
else we won’t have a sustainable health care system here. And we should acknowledge that, on average,
all doctors in America are paid higher than their overseas counterparts. But we should also agree that expenses for
doctors to earn a degree, maintain that degree and licensure, and pay their malpractice
premiums is also much higher than the rest of the world.

So why has Elisabeth Rosenthal of the New York Times decided
to bash specialists with her front page story entitled “Patients’ Costs Skyrocket;Specialists’ Incomes Soar”?Perhaps the
subtitle of the story explains part of the reason: “When a Doctor Becomes an
Entrepreneur, Small Procedures Offer Big Returns.”

We should acknowledge that several moons have aligned that make such an article
newsworthy.

First, of course, is the remarkably unaffordable Affordable
Care Act.The new law is confusing for
patients (to say the least).Not only
are terms like deductibles, co-pays, subsidies, and co-insurance confusing, there
is absolute uncertainty about which doctors or health care system can provide once their insurance is purchased.Is a doctor
“in-network” or “out-of-network?” What, really, do I get for Platinum, Gold, Silver, or Bronze coverage? How
many mental health visits can a patient have with their particular policy? Because every one of the hundreds of different policies has different “rules,”
patients are left to fend for themselves like never before.Patients are confused.Doctors, having little clue about anything
regarding such care limitations and cost structure, also have little
understanding about the programs sold, so they become easy targets.

Second, is the current political pressure to develop physician payment reform.It has long been known that
health care was on an unsustainable cost path.Numerous Congressional fiats have been used to control physician
costs.There was the Medicare Volume
Performance Standard (MVPS), for instance, that was later replaced by the infamous and
never-enforced Medicare Sustainable Growth Rate (SGR).Why hasn’t Congress enforced their own
law?Simple: because doctors matter to
seniors worried about health care and seniors vote.Oh, and doctors take care of Congressmen,
too. But let's not mention this, Ms. Rosenthal - you see Americans might think their doctors are actually worth their salaries.

Third, was the Stimulus Package, formerly known as the
American Recovery and Reinvestment Act of 2009 used to bolster the American
Economy.Within the confines of this
bill were several features that laid the groundwork to the later Affordable Care
Act.These included the Health
Information Technology for Economic and Clinical Health Act (HITECH Act),
another 25.8 billion for information technology, $1 billion for “health and
wellness”, $1.3 billion for “comparative effectiveness research” and (most
important for specialists) a 40% cut to Medicare technical revenues to
specialists who perform office-based procedures without a corresponding cut to
similar fees paid to hospitals.This
final provision proved devastating to private specialist offices nationwide,
forcing most of them to become employees of large health are systems.The move was massive and has forever changed
patients’ access to their physicians and elevated costs for them dramatically.With such a move, doctors must now serve two
masters: their employer and their patients.All those pretty buildings, big screen TVs, administrator salaries, CEO
salaries, and computer systems are very expensive.Gee, who knew specialists’ bills would
skyrocket as a result? Yet according to Ms. Rosenthal, it's the specialists' fault.

But this is not the entire story.While specialists' bills have skyrocketed,
their incomes have not.I should know,
because unlike Ms. Rosenthal, I am a real live US specialist and I have the
W-2’s to prove it.Again this year,
another $20K less.

Why?I believe this
year’s cut was due to how I am paid.(Because I am sworn to secrecy about such issues by my employment contract,
I can’t delve into all the details, but let’s acknowledge to points: (1)
productivity is important to employers since they want to get the “most bang
for their buck,” and (2) most doctor’s
work is “valued” based on a Medicare metric called “Relative Value Units.” )

This post is already
too long to delve into details about how procedures are “valued” by the system,
but suffice it to say, they are.Every
procedure has an RVU value.The more you
do, the more you get credit for.This
really bothers policy wonks who feel this is the single reason costs are so
high in medicine.Never is mentioned the
next fact: that Medicare has a habit or “bundling” several procedure codes into
one to cut costs already.What does this mean
for the doctor?It means they earn fewer
RVUs for the same work.So doctors are
spurned to do more and more to make up the difference.

Until they can’t any more.After all, there are only so many hours in the day.

Last year my specialty had a huge change in RVU values for
our expensive specialty, and because I am well-established, I have lots and
lots of patients in my clinic.Adding
new ones has become nearly impossible.But new patients means new procedures.And without procedures, I invariably have my pay drop thanks to these hidden changes to how I am paid.

Finally, there’s the problem of Ms. Rosenthal’s salary
data.She received it from an
industry-standard company that makes money reporting physician salaries to
hospital systems.They claim their data
is based on physician salary surveys, but I for one can attest that I have NEVER been asked to reveal my salary to this company.Could they be getting their data from
hospital systems instead?Of
course.

I have had the opportunity to inquire about the MGMA’s data
for my subspecialty of cardiac electrophysiology.Their dataset supposedly
represents only about 400 physician salaries (10%) of the entire nation’s 4000 or so electrophysiologists. We have no idea where these data were collected. Yet the salaries are stratisfied by RVU productivity
into percentiles: 10%, 25%, 50%, 75% and 90% or better.If you earn only a 10% RVU value, you are a
dog in an employer’s eyes.If you are
90% or better, you are worshiped.

But for electrophysiology, several interesting tidbits
exist: to achieve a 90% RVU value, the MGMA says that doctors must achieve over
19,000 RVUs per year as a specialist. Now I work my fanny off.
I am on call every third week. I
cover four hospitals and do plenty of procedures. I have never made that kind of RVU productivity
as shown in the 90th percentile.
Not even close. Might this be a unachievable carrot that is being dangled before specialists' eyes?

I was so amazed by that statistic touted by the MGMA that I
asked our hospital administrative leadership to identify who the institution (or doctor)
was that was producing like that.After
all, if I could learn how they are producing, I might be able to improve my efficiencies, right?Yet because the MGMA’s “benchmarks” are
proprietary property, no one could identify the physician producing like that.

Which brings me back to the salary figures Ms. Rosenthal
quotes in her inflammatory front-page story in the New York Times.They are non-transparent.They are skewed and cherry-picked to make her
point.And while some salaries might be
representative for some areas of the country, I suspect most are not – especially for those in competitive
health care markets.Ms Rosenthal never
mentions the regional differences in physician salaries that exist.

It seems there remains a real need to demonize physicians,
especially specialists, as we proceed in health care reform.In a system that has devalued primary care so
dramatically, perhaps this is a way to gain favor for a shift in salaries to
the primary care doctors.Perhaps it’s a
need to cut costs for large hospital systems that jury-rig their compensation
structures on non-transparent benchmarks like the MGMA.Whatever the reason, specialists’ salaries,
jacked up my hospital systems eager to hire the most marketable talent, will remain
easy targets.After all, it’s much
easier to point the finger at specialists that struggle to see all of the new
patients, than to acknowledge the shortcomings of the very system that has
gotten us where we are today.

Case in point: Most hospital-system CEO’s in Chicago
salaries exceed many millions of dollars.Salaries and benefits of pharmaceutical and insurance companies exceed
ten times that of hospital system CEOs.

But better that Ms. Rosenthal doesn’t mention these salaries
or the other infrastructure changes that have gotten us where we are
today.After all, it’s much easier take
a cheap shot at specialists in the New York Times.

9 comments:

Good points made here on the quality of the data used for the article. This is a big deal today and I wrote about it and the rise of the "jounobot" and some of the "news content farms" that are on the rise.

Forbes who is trying to sell their media company has a bot that writes some of their articles and they have been up front and open about it.

Journalism is changing when reporters "interview a data base"..and again what is the quality and source of the data? See the video on the patented "high tail" software that can write books too..almost scary automation there but good to be aware that it exists and is out there...

In addition I talked in another post about CMS and their new disclosure on making doctor payment information available, well here too I said it's a boom for journalists to "interview that data" and create news articles based on their opinions and findings, in other words what context they used for their articles. This is a big deal and I included a video with an editor at the Economist where he talks about interviewing data bases and the changing face of journalism.

In some places and you and I would probably do the same if it were our job, reporters are graded or paid on clicks as they get revenue from ad exposure so if you want your job, what do you do? I'm not picking on journalists in that respect but it's the world built for the to operate with in, so just something to keep in mind as there's old pay for performance there too and it has an impact on what we read and get to read. Pay for performance can be dangerous in other areas as well as healthcare:) Professor Siefe from NYU, who's clips I used has another book in the works and he told me the other day there will be a chapter that covers the rise of the journobot, anyway, I hope maybe this little bit of information might help explain a bit of what's going on out there:)

The Times article was a politically motivated, factually inaccurate, misguided attack on physicians. As "Medical Quack" says - if some medical specialists are only motivated by dollar signs then I guess some journalists are only motivated by readership numbers? She certainly used random anecdotes and data cherry-picking to rile up the uninformed. She'll probably be praised for all the web traffic her article generates - which will reinforce to other journalists that they should engage in doctor-bashing. Viewing this article in the context of my specialty locums work in underserved parts of this country, fighting for CMS approval for wheelchair parts for my patients with cerebral palsy, I can only say - Rosenthal, you are embarrassingly clueless about specialty healthcare and have committed journalistic malpractice with this article.

2. Our ambulatory cath lab sustained such huge Medicare cuts that it was closed and all the procedures moved to the hospital. The cath lab could do a cath for $1500. The hospital charges $10k for the same procedure.

3. A plumber will expect to receive payment in full for each repair. Medicare will pay a cardiologist half for each added procedure. Next time your plumber fixes a toilet tell him that the sink is half price.

4. The author states the the family care doctor missed the skin lesion yet she argues that they are underpaid. Where is the logic with that?

5. Our European colleagues supplement their public health system pay by seeing patients on the side charging higher fees. This is not reported in this article. Once again, poor fact checking. Also, European physicians are less regulated and receive payments from big pharma and industry.

As an interventional cardiologist, I am paid about $1200 to save your life from a heart attack at 2am. That is including the admit, angiogram, stent, rounding, midnight calls from the nurse and discharge. The hospital will bill your insurance $30k to cover Michelle Obama's salary.

The usual NYT crap. "Doctors make too much money. In fact everyone makes too much money except government workers and journalists."

The lobbying angle is interesting; it would have been nice if the writer had compared what doctors spent ($80 million in total) to AFSCME ($65 million), and the AFL-CIO ($22 million) and the SEIU ($18 million) but that would have required that she commit journalism.

Wes, If you have not submitted this blog to the NYT as an "editorial reply", you should, as your comments are on the mark. And, you have taken the trouble to break down the cause-and-effect of how we got to where we are, something the author did not really do oomprehensively. Thanks. -David Share MD

As far as the 19000 RVU its possible of course. You can query the publicly available Medicare data - payment for physicians. Search who is the top paid EP in your state and you will be amazed. What is fascinating is that the major source of RVU is not procedures as it is widely believed. These are very busy all around EP - seeing 10 consults per day, reading massive amounts of ECG/Holters and having many device interrogations. Its all in the set up. These guys have nurse practitioners who run around and see patients. The EP just sign. If you think you can make 19 000 RVU by doing AF RFA - that is not possible of course.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.